Pain Management and Safe Prescribing › content › dam › nursing › docs...Ohio and U.S....

Pain Management and Safe Prescribing

Cleanne Cass, D. O., FAAFP, FAAHPMAppointed Member, Governor’s Cabinet Opioid Action TeamCo Chair, Treatment Work GroupOhio Prescription Drug Abuse Task Force

Why are we here today?

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Today:An “Epidemic of Opioid Overdoses in

the United States and in Ohio?

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Ohio and U.S. Unintentional Drug Overdose Death Rates per 100,000 Population

1999-2006 U.S. /1999-2008 Ohio

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Number of Deaths from Motor Vehicle Traffic, Suicide and Unintentional Drug Poisonings by Year in Ohio 1999 – 2008

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Contributing Factors to Rising Fatal Drug Death Rates

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Unintentional Fatal Drug Poisoning Rates and Distribution of Prescription Opioids in grams per 100,000 Population by Year -

Ohio 1997 – 2007

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Unintentional Drug/Medication Poisoning Death Rates per 100,000 by County 2004 – 2008

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In Ohio:

Over 931,000 adult and 231,000 children with chronic malignant and non-malignant painOhio Compassionate Care Task Force, 2004

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The Provider’s Dilemma:“Twin serpents in the Caduceus”

Undertreated Pain and related costs:- Nationally 100 million Americans with

chronic pain at a cost of >635 billion dollars

IOM Report on Pain - 2011

Opioid Abuse and related costs- Nationally > 6 million Americans abusing

opioids at a cost of 70 billion per year Money Magazine

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THE CHALLENGE : How to prevent abuse and diversion and still safely treat the over 1million Ohioans who live with chronic pain

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As the gatekeepers of prescription medications physicians are being charged with fighting on two fronts: combating pain while defending against misuse of opioid medications!

Is Pharmaco Vigilance more than we can ask of Physicians ??

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Review of death certificates: majority of opioid related deaths involve other substances -marijuana, cocaine, alcohol

Chronic pain patients not the ones dying from opioid overdoses

Millions of opioid doses are reaching the wrong hands!!

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Examining the data more closely:

“ It is unclear how much abuse, diversion and addiction is the result of well meaning but under-educated or under-informed physicians.”

Fish, P8

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Institute of Medicine Report – June, 2011

Treating pain is a moral imperativeImproved efforts to prevent pain are needed Increased research/ education on pain is neededA biopsychosocial model of pain management improves outcomesA transformation is needed in our cultural view of pain

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Treating Pain –A Moral Imperative

Eighty percent of patients presenting for health care have pain

Undertreated acute pain may become chronic disabling pain: complex regional pain syndrome

Under treatment of pain can lead to alcohol and substance abuse; isolation, depression, and institutionalization in the elderly

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“Physicians need training and experience in pain management if issues of access and under treatment are going to be addressed”National Pain Care Policy Act of 2009 Incorporated into the Obama Healthcare Reform Bill

The real issue for prescribers in Ohio’s Pain Epidemic is not whether or not to treat pain but how!

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Two imperatives:

To treat pain in a manner that is safe and effective for the patient

To understand and implement Ohio’s regulatory oversight in order to protect our prescriptive rights

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Today’s DiscussionRegulatory Oversight in Ohio

Safe and Effective Pain Management

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Regulatory Oversight

CDC guidelinesOhio’s Automated Rx Regulatory SystemOhio’s Intractable/Chronic pain lawEmerging actions: Emergency Department Guidelines for Pain Management

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CDC Guidelines: Epidemic: Responding to America's Prescription

Drug Abuse Crisishttp://www.cdc.gov/mmwr/preview/mmwhtml/m

mwrhtml/mm6101a3htm? cid=6101a3wSpecifically address the concern of access to

care for patients and the need to address the significant concern and expense of untreated pain

These serve as guidepost for the states – they are specifically Guidelines and not Laws

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CDC Guidelines

Epidemic: Responding to America's Prescription Drug Abuse Crisis, The Administration's plan for addressing prescription drug abuse released in April 2011: four components:education, tracking and monitoringproper medication disposal,enforcement.

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Ohio Automated Rx Regulatory System: OARxRS

Ohio Revised Code – 4729.75-4729.84Tool for prescribers, pharmacists to identify and prevent abuse and addictionTool for law enforcement to deter diversionPharmacists must enter data electronically weeklyReported drugs: schedule CII, CIII, CIV ,V,

Carisoprodol (Soma)& tramadol ( Ultram)

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OARxRS

Who can access OARRS?Pharmacist – own customer onlyPhysician – current patient onlyPhysician’s non licensed designee (HB93)Individual – own reportLicensing boards – own licensee

Law enforcement - only as part of a certified active investigation of suspected diversion, abuse or drug trafficking

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OARxRS: HB 93 expanded use

Physician’s designee may obtain dataPhysician dispensing reported drugs from office must enter data into OARRSRestricted dosage units furnished per month by prescriberPhysician dispensing of reported drugs limited to a 72 hour emergency supply

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HB 93 April 2012 expanded use of OARRS:

Wholesalers must enter all salesPenalties for abuse/ misuse of OARRSLicensing boards must develop rules governing the use of OARRs by their licensees OSMA, OSBP, etcCoroners must report deaths

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HB 93 April 2012 expanded required use of OARRS: Medical Board Rule

4731-11-11

Mandated OSMA to develop rules for when physicians must access OARRS:

1. If patient exhibiting signs of drug abuse or addiction

2. Treatment of patient with reported drugs >12wks

3. At least annually if using reported drugs.12wks or more per year

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HB 93 expanded use of OARRS: Medical Board Rule

4731-11-11 FAQ Document

Signs of abuse or addiction:Patient with un expected drug screen Forging/adulterating script

Stealing/borrowing medsHistory of illegal drug use/ conviction

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Signs of Abuse/Misuse –Mandate OARRS Check:

- Selling drugs- Increasing the dose without permission- Multiple prescribers identified/suspected- Family member, friend or other professional

raises issue of patieint abuse/misuse

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“Red Flags” –Suggested to check OARxRS but not

mandated:

History of chemical abuse/addictionPatient appears sedated /impaired in officeLoosing scripts or requesting early refillsED visits for refillsSharing drugsRequesting drugs by name ???

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OARxRSThe report is privileged health information (HIPPA), not a public record, not evidenceYou may not share the information with other professionals unless they use the same chartYou may show the patient the data but not give it to themYou must keep OARRS report in non reproducible part of chartYou may not use OARRS to screen employees or potential employees

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OARxRS

Exemptions:

Prescribers of patients with a terminal illness

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OARxRS is meant to be and is a useful tool in pain mangement!

OARRS can be a useful tool for initial or ongoing patient assessment

OARRS is just one more piece of the clinical assessment; it does not replace your medical judgment

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Ohio Automated Rx Regulatory System: OARxRS

In 2011 :Ohio Population approximately 11million

Scripts in OARRS:46.9 million#of patients in OARRS: 5.7 million

Time to get report: 98% within 23 seconds5% 5mins -3hrs reports available 24/7 Lag time of 1-10 days from dispensing of

medication until report available

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Signing up for OARxRSGoogle OARxRSHome page – “Register”

- registration takes about 15 minutes

More information – Questions??Danna E. Droz, J.D., R.Ph.PMP Administrator

614-466-4131 option 1oarrsadmin@ohiopmp./gov

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Ohio’s Intractable (Chronic) Pain Law

Chapter 4731-21 Drug treatment of intractable pain Effective date: November 11, 1998Changed to “Chronic” in HB 93Currently under review with expected new rules to be developed by the Govenor’s Cabinet Opioid Action TeamHotly debated issue: will recommendations of the team be “guidelines” or “rules”? –

Should vs. Shall!

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Current “Shalls” in the law:Initial evaluation documented in the reordMedical diagnosis establishedIndividualized treatment plan formulated and documentedAppropriate consultationSigned consent to treatment and agreement to conditions of prescribing

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Patients shall be seen at appropriate intervalsDocumentation of effects of treatment on the functional capacity and efficacy of the treatmentMonitoring for compliance if needed ( drug screen, etc)Referral to addiction specialist if indicated

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Exemptions : 4731-21-06Treatment of patients with a terminal illness

or treatment of pain associated with a progressive disease that in the normal course of progression may reasonably be expected to become terminal

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Governor’s Opioid Action Team

Ohio Emergency and Acute Care Facility Prescribing Guidelines: Opioids and Other Controlled Substances (OOCS) These are guidelines, not rules: shouldand not shallDeveloped to assist ED physicians who are struggling to deal with the impact of chronic pain patients on the ED, as well as the ever present drug diverter and abuser

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Ohio Emergency and Acute Care Facility Prescribing Guidelines: OOCS

OOCS for pain will be prescribed only after evaluation of patient and risk of addiction

OOCS should be given P.O., not IM/IV

No Rx if patient seen within the last month or had Rx from another prescriber within last month for the same problem

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Meperidine ( Demerol) use discouragedED clinicians will not routinely provide replacement scripts for OOCS that were lost, stolen or destroyedReplacement doses of Suboxone, Subutex, or methadone will not be given for patients in treatment programs

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Long acting or controlled release formulations such as oxycodone SR, fentanyl patches methadone will not be routinely provided

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Prior to deciding whether or not to treat with an OOCS the ED clinician or the facility: Should access OARRSCheck a photo ID or photograph patient for the chartReserve the right to perform a drug screen

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ED clinicians should consider contacting the physician who routinely prescribes for the patientRequest a Palliative Care or pain consult, or other appropriate subspecialty service Perform case management on patients repeatedly seen in ED

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Request medical and prescription records from other hospitals/prescribersRequire that the patient sign a pain agreement outlining expectations of the ED department regarding the patient’s use of the OOCSUse EMR to communicate with other providers regarding patient care

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Limit the Rx of OOCS to a 3 day supply except in unusual circumstances

Discharge instructions to patients given an OOCS Rx should include information on addiction risk, dangers of misuse, appropriate storage/disposal of OOCS

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ED and other facilities should maintain a list of clinics that provide primary care services and pain managementED and other facilities should display signage that reflects these prescribing guidelines and states the facility position regarding the prescribing of opioids and other controlled substances

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Ohio Emergency and Acute Care Facility Prescribing Guidelines

Endorsed by:OOAOSMAOHOOhio Pharmacists AssociationOhio Chapter of the American College of Emergency PhysiciansOhio Association of Health PlansOhio Association of Physician AssistantsOhio BWC

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8 Steps to Safe and Successful Pain Management

Step 1: Reframing the discussion –realistic expectationsStep 2: Utilizing a biopsychosocial model of pain management vs. the biomedical modelStep 3 Evaluation of the pain patientStep 4 Evaluation of the pain

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Steps for Successful Pain Management

Step 5 Multimodal pain managementStep 6 Initiating opioid therapy when neededStep 7 Monitoring ongoing opioid therapyStep 8 Celebrate Success!

Extracted in part from Scott Fish: Responsible Opioid Prescribing

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Step 1: Set Realistic Expectations

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• A good outcome is achieved if the patient’s pain is reduced by 30 points on a 100 point scale, or by 2-3 /10

• Success should be measured in terms of improvement in lifestyle and function

• Set realistic expectations from the start: what is it that the patient would like to do that pain is preventing? Take mini steps toward achieving goal

Step 2: Utilize a Biopsychosocial Model vs a Biomedical Model of Pain Management

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What does this mean?

Treat the patient instead of the pain!

When evaluating patients do so in terms of the affects of the pain on lifestyle, function, productivity: ask the patient:“How does this pain affect you – What can’t you do that you want to do? What can’t you do that you need to do?”

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Assess the “meaning of the pain”to the patient:

Secondary gain or alienation from family, work or society may be hindering patient’s response to treatment

Patients living with pain have depression that is chemically medicated – depression is a proven biologic outcome of chronic pain - address openly with the patient!

assure the patient that you don’t think the pain is “all in his head”, but that addressing depression will be part of treatment plan

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Assess sleep, activity, sexual response in relation to the pain; fatigue will increase pain, pain is worse at night

Actualize patients’ personal satisfaction in their ability to manage their pain’s psychosocial implications: reward gains in function and activity

Utilize interdisciplinary case management as early as possible: pain psychologists, PT, OT, vocational counselors

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Tools for assessing pain in terms of function and lifestyle:

Pain / disability indexSickness Impact Scale

Documentation of improvement in function and activity as a result of using opioids justifies their use for reviewers

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Step 3: Evaluation of the Chronic Pain Patient

• Requires time to evaluate the patient as well as the pain and to build a trusting relationship

• Requires utilizing staff and assessment tools when appropriate to evaluate the patient and the patient’s appropriateness for treatment

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Patient Assessment

One out of every ten patients with no history of addiction is at risk for opioid addictionGenetic incidence similar to prevalence for alcohol addictionEducate patients and families about genetic risk (use handouts from ODADAS) and take a history of family addictions

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Tools to assess risk for addiction

SBIRTOpioid Risk Tool (ORT)D.I.R.E. Score: patient selection for chronic opioid useCAGE-AID – alcohol assessment tool adapted to include drugsSOAPP-R –SODQ

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Patient Assessment

Use OARxRSMandated Use:

1. If patient exhibiting signs of drug abuse or addiction

2. Treatment of patient with reported drugs >12wks3. At least annually if using reported drugs.12wks

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Patient Assessment

“Red Flags”: optional use of OARxRS

OARxRS can be a useful tool for initial or ongoing patient assessmentDocument the use of tools in your medical record – may be mandated in state guidelinesPatients with terminal illness/ illness that may become terminal are exempted from OARxRS

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Patient Assessment

Physical examination of the patient: never prescribe an opioid for a patient without documenting a physical exam

4731-21-02, O.A.C.

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Step 4: Pain Assessment

In order to manage pain, the prescriber must be able to determine the anatomical origins of the pain; somatic , visceral, neuropathic

Detailed history and listening to your patient’s describers of the pain will reveal its anatomical origin

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Patients with chronic pain will have more than one type of pain –

Ability to control pain depends on choosing the correct medication for each type of pain the patient describes

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Mnemonic for Pain Assessment

P – palliating/precipitatingQ – quality of the painR – region/radiationS – severityT – temporal relationshipsU – impact of the pain on you

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Anatomical Origins of Pain

Somatic pain

Visceral pain

Neuropathic pain

Complex neuronal pain

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Anatomical Origins of Pain: What is Chronic pain??

Complex Neuronal Pain – Chronic painWhen patients live with pain, the brain’s

response to the pain changes d/t changes in neurotransmitters and neuroreceptors

Down regulation of Mu receptors (opioid receptors) up regulation of Delta, P, NMDA receptors (neuropathic receptors)

Therefore, in chronic pain, patients are less receptive to opioids and more receptive to neuropathic pain medications 68

Complex Neuronal Pain

Primary neuronal deathLoss of myelin sheathCentral sensitizationChanges in neurotransmitters, neuroreceptors

Opioid receptor down-regulationincreased importance of NMDA receptors, glutamate

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Acute vs Chronic Pain

Acute pain is very easy to localize and describeUp regulation of the sympathetic nervous system leads to physiologic response of the body that can be measured: increase in BP, pulse, respirations, anxietyIn chronic pain: less response of the SNSPain descriptors become more vague and pain more diffuse, patients use neuropathic pain descriptors and have flat affects

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Step 4: Develop a treatment plan

Use a biopsychosocial model of pain management: integrative (integrative) medicineSelect appropriate medications that address the patients multifaceted painEmphasize achievable goals directed at function that are taken in “baby steps”The sooner, in the course of the illness, the function is addressed and the patient increases activity, the more likely the treatment will be successful

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Develop a Treatment Plan

Discuss the plan with the patient/familyEmphasize lifestyleSet the rules – consider a pain contract/ patient agreement, informed consent?When you see a patient in acute pain, get the patient moving as quickly as possible!

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Step 5:Utilize Multimodal Pain Management

Physicians often equate pain management with opioids or interventions by pain specialists.

Good pain management is “multimodal”and can be accomplished in the office of the attending physician.

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Multimodal Medication Therapy

Pure opioids, weak opioids and Adjuvant medications chosen to address the specific aspects of the patients “total pain”including psychosocial aspects of the pain (depression, sleep, anxiety)Initially treat without an opioid if possible, or with limited quantities of opioids

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Analgesic Classes

Non opioidsWeak opioidsPure opioidsAdjuvants

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What are Adjuvants in pain management?

Adjuvants may be analgesics themselves, or medications not commonly considered to be analgesics, such as anticonvulsants, anxiolytics, and antidepressantsEnhance or augment the main analgesicReduce the total opioid load if an opioid is neededAddress different aspects of the patient’s total pain

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Adjuvant Medications…NSAIDS:

Examples: Naproxen, Motrin, Celebrex, Toradol *relieves bone, muscle, or joint pain * often better than Morphine for bone pain

Antidepressants:Tricyclics – Examples: Elavil, Doxepin

*increases endomorphins*helps neuropathic pain*may provide appetite stimulation, mood elevation

SSRIs – Examples: Paxil, Prozac, Zoloft*improve sleep, mood appetite*have not been shown to help neuropathic pain

SNRI – Example: duloxetine (Cymbals),venlafaxine

Topical Agents:capsaicin, lidocaine patch, EMLA

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Adjuvant Medications…

Anticonvulsants:Examples: Tegretol, Dilantin, Neurontin

*relieves neuropathic pain

Steroids:Examples: Decadron, Prednisone

* reduces swelling in brain or visceral lesion* improves appetite* may improve mood* relieves neuropathic pain* serves as an anti-inflammatory if NSAIDs are contraindicated to reduce joint or bone pain

Antianxiety Medications:Examples: Ativan, Xanax, Haldol

* treats agitation, restlessness, extremely helpful in dyspnea, COPD, terminal delirium

* important adjuvant in controlling pain of all etiologies

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Adjuvant Medications…

GABA Agonists* Baclofen

NMDA Antagonists* Dextromethorphan, ketamine

Scopolamine: Patch or SQ, Levsin PO, Atropine PO or SQ* treats terminal secretions, relieves death rattle, may help

stomach, colic spasms* motion induced nausea, dizziness

Bisphosphates, Miacalcin, Arida, Zometa* bone pain* may retard bone fracture* treat hyperkalemia* hypercalcemia

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Adjuvant Medications…Alpha 2 –adrenergic agonists:

* Clonidine

Neuroleptics* olanzapine* Haloperidol* mirtazapine

Muscle Relaxants – Flexeril, Baclofen

Adjuvants may be analgesics themselves, or medications not commonly considered to be analgesics, such as anticonvulsants, anxiolytics, and antidepressants

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The Concept of Total PainTumor – 60% of pain directly related to tumor

19-28% of pain is secondary to side effects of treatment

Pain from debilitation, malnutrition (bedsores)

Pre-existing Pain

Brain Mets

Radiation

Surgery

Chemo

Bone MetsVisceral Mets

Total PainOncology

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End Stage Cardiac Disease

Pleural Effusion

Peripheral Edema

Cardiac Cachexia Wasting,

Bedsores, Debilitation

Dyspnea

Ischemic Coronary Artery Disease

Aortic Insufficiency –Chest Pressure

Co-MorbiditiesIschemic Bowel Peripheral Vascular DiseaseRenal NeuropathiesOsteoporosisVenous Insufficiency

Medication Induced Hypokalemia Hyponatremia

Total Pain In

Cardiac Disease

Acute/Chronic Angina

Depression

Chest Wall Pain

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Chronic Obstructive Pulmonary Disease

Chronic anxiety, depression

Wasting, cachexia,Chronic debilitation, bedsores

Osteoporosis

Chest wall pain, chronic pleuritis

Chronic racking cough

RHF – Chronic tissue edema hepatomegaly

Peripheral vascular diseaseVenous insufficiency

Total Pain in

COPD

Pain in COPD is a combination of the pathophysiology of the primary process and the multiple common co-morbidities

Pain from pre-existing etiologies

Tachypnea

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WHO 3-step Ladder

1 mild

2 moderate

ASA

Acetaminophen

NSAIDS

+ Adjuvants

3 severe

A/Codeine

A/Hydrocodone

A/Oxycodone

A.Dihydrocodeine

Tramadol

+ Adjuvants

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone

+ Adjuvants

< 4

> 4 - < 7

> 7

Treatment of Acute Pain

Failure to treat acute pain preemptively can lead to development of chronic pain such as complex regional pain (RSD)Plan for successful management rather than reacting to failed treatment!

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Treatment of Acute Pain Case Study

Case scenario: middle aged patient with ankle pain comes in the office on a crutch after an injury playing basketball. Patient rates his pain as a “6/10.” No history of opioid use or drug/alcohol abuse

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Treatment of Acute Pain – case study:

Screen for abuse potential using appropriate tools

Check OARxRS if any “Red Flags” or just because “who can tell!”

Physical exam is compatible with the history; 2nd degree ankle sprain

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Treatment of Acute pain

Goal of treatment is to reduce the pain to the point that patient can remain functional and able to say that he can move about comfortably with minimal pain and is able to sleep through the night

One recipe: Naproxen 500mg 2xday p.o RTC for 10 days, hydrocodone 5/500 Tab 1 q4hrs prn p.o. for severe pain breakthru – dispense 16 pills gabapentin 200mg qhs p.o to address the neuropathic component of the pain ..

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Treatment of Acute Pain

Patient advised to call you ASAP if not meeting the expectations/goals described above

See patient back in the office in one week - prescribe very few if any opioids and start PT/OT – set goals for return to activity

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Treatment of Acute pain

This is “multimodal” because instead of using only the opioid/ acetaminophen combination you are also using an anti-inflammatory for the somatic pain and gabapentin for the neuropathic component of the pain. You are scheduling the naproxen and using the hydrocodone/acet prn so that you are giving both RTC continuous relief but sparing the opioid use.

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Treatment of Chronic Non Malignant Pain

Case scenario: Beth has chronic pancreatitis and a pancreatic pseduo cyst. She has had repeated surgeries and has abdominal adhesions. Beth is also diabetic and has significant peripheral neuropathy. She is frequently hospitalized, losing weight, depressed and sleeps poorly. Beth sees several specialists but looks to you to manage her pain.

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Treatment of Chronic Pain

Does Beth qualify as having “intractable pain” under the guidelines of Ohio SHB 187, “The Intractable Pain Law”?

Does Beth have pathology that could result in a terminal condition?

If so, then you and Beth are excluded from the regulatory scrutiny of pain contracts, urine screens, pill counts.

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Document heavily, particularly the beneficial effects of your treatment on Beth’s lifestyle and function

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Treatment of Chronic PainOne multimodal recipe for Beth:

Beth has been on oxy/IR 10 mg 6xday for several months, now her pain is worse and she wakes up at night with leg pain and numbness. Convert the oxy IR to oxycodone SR, 20mg 2x day; and continue the oxycodone IR for “break thru pain” every 2-4 hours prn, Start gabapentin for the neuropathic pain in her legs starting with 100mg 3xday, gradually titrate to comfort by increasing the dose in tolerated increments until acceptable relief of neuropathy pain is achieved, taking into consideration Beth’s GFRSRNI for neuropathic pain and depression and sleep Anticholangeric for bowel spasms

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Use of the gabapentin will not only help the diabetic neuropathy, it will also potentiate the effect of the opioid and address the “complex neuronal pain”which develops when pain becomes chronicUse of the adjuvants reduces the total mgs of opioid needed to provide comfort

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Step 6: Initiating opioid therapy for Chronic pain when necessary

Criteria: goals without opioids have been disappointing, reason to believe they are indicated (pathology involved, physical exam, pt’s need for relief in order to obtain function)Assessment of patient, screening indicates patient is appropriate candidate for opioid therapyA pain contract, patient agreement, consent to treat as appropriate are in place and documented

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Initiating opioid therapy for chronic pain

Pretreatment urine screening if appropriate is complete and documentedEducate the patient about the possible side effects of opioids and how to manage: sedation, confusion, itching ,nausea hypogonadism, secondary osteoporosisInitiate a “ trial period’ with set goals and expectations of the patient’s functionEstablish a plan to taper and d/c opioids when appropriate

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Initiating Opioid therapy

Discuss safe storage of medications and review concerns about diversion in the household by friends and relatives

Discuss safe disposal of unused medications – office handout on these subjects

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Step 7:Monitoring ongoing Opioid Therapy

Utilize “Universal Precautions for Pain”Monitoring plan is in place and initiated prior to start of therapyComply with established and evolving state and federal regulations Comply with OARxRsDocument monitoring, compliance on part of patient, improvement in function, achievement in goals especially work related

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Monitoring ongoing therapy

Continue all integrative medicine as appropriateContinue to use a biopsychosocial model of patient and family managementPositive reinforcement of patients improved coping and lifestyle skills

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Step 8: Celebrate Success!!

Document the improvement in terms of sleep, function , ADLs, independence in the elderly

Taper and d/c opioids as patient’s overall condition and coping skills improve

Positive feed back to patient, family and staffHave ODADAS send you handouts, signs for office and update info regularly

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Safe and effective pain management

Trust your real patients, and if you don’t, don’t treatHelp your real patients who have substance use problems success is improvement in function/ productivityUse adjuvants to treat complex painPrescribe opioids in appropriate quantities and address issues of diversion/ drug disposal with patients.

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References

Fishman, Scott M. Responsible Opioid Prescribing, 2nd edition, Waterford Life Sciences, 2012 pp 1-129Institute of Medicine: Relieving Pain in America, a Blueprint for transforming prevention, care, education and research. Report Brief, June 2011APS- AAPM Clinical Guidelines for Opioid Use in Chronic Non Cancer Pain 2009

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References

AAFP Monograph: Balancing Clinical and Risk Management Considerations for Chronic Pain Patients on Opioid Therapy, October, 2008Office of National Drug Control Policy Action Plan epidemic: Responding to America’s Prescription Drug Abuse Crisis, 2011Veteran’s Affairs/Department of Defense; Clinical Practice Guidelines Summary Management of Opioid Therapy for Chronic Pain, 2010

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Transcript of Pain Management and Safe Prescribing › content › dam › nursing › docs...Ohio and U.S....